GW1-2022-03328_Well Construction - GW1_20220314

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Anthony ConVery 74.WATER ZONES
FROM TO DESCRIPTION
Well Contractor Name ft. ft.
4343 ft. ft.
NC Well Contractor Certification Number 15.OUTER CASING,for mu1H-cased welIS)'OR LINER if a licablI
FROM TO DIAMETER t THICKNESS MATERIAL
Parratt-Wolff, Inc. ft. ft.
Company Name 16.INNER CASING OR TUBING eotliermal closed-loop)
FROM TO DIAMETER I THICKNESS MATERIAL
2.Well Construction Permit 4: 0 f" 12 ft. 4 in.' sch40 PVC
List all applicable Drell permhs(i.e.Couniv.,dale,variance,Ittjechon,e1.)
ft. ft. in.
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3.Well Use(check well use): 17.'SCREEN
Water Supply WeII: FROM TO DIAMETER SLOTSIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public 12 ft. 37 ft. 2 in. .010 sch40 PVC
❑Geothermal(Heating/Cooling Supply) ❑Residential Water Supply(single) tt. ft. in.
❑Ind ustrial/Com mere ial ❑Residential Water Supply(shared) 18•GROUT it
FROM TO MATERIAL EMPLACEMENT RIETHOD&AMOUNT
❑►rri ation 0 ft
8 rt. Portland Cem Tremie
Non-Water Supply Well:
OMonitoring ❑Recovery
8 ft
10 ft• BentonitelChil Tremie
Injection Well: R. ft.
❑Aquifer Recharge ❑Groundwater Remediation 19.SAND/GRAVEL PACK if a licable
FROM TO MATERIAL! EMPLACEMENTMETHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier
10 ft• 37 ft• 1 #1 Sand I Tremie
❑Aquifer Test ❑Stormwater Drainage ft. I ft.
❑Experimental Technology ❑Subsidence Control
20.DRILLING'LOG attach a8ditiona191ieets if necessary)
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION cumq hardness,st,ith—k ty1m, rain size,etc.
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) ft. ft.
ft. ft.
4.Date Well(s)Completed: 1-28-22 Well ID#AF-1 A
ft. ft.
5a.Well Location: ft, ft.
Colonial Pipeline Company ft. ft.
Facility/Owner Name Facility IDtt(ifapplicable) ft. MAR 1 4 202?
14511 Huntersville-Concord Road, Huntersville, NC 28078
Physical Address,City,and Zip -'
.21.REMARKS
Mecklenburg € I
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22•Certification:
(ifwell field,one la(/long is sufficient)
35.415038 N -80.806015 W 4 as
Signature ofC rtitied ell Contractor Date
6.Is(are)the well(s): ©Permanent or ❑Temporary ev signing this fbrnt,l herehv cerlifj,that the urell(s) rras(were)constructed in accordance
frith 15A NCAC 02C.0100 or 15A NCAC 112C.0200 Well Conelrucliun J'lundards and than a
7.Is this a repair to an existing well: ❑1'es or ZlNo copy ol'Ihis record has been prorided Io the Abell owner.
q this Is a repair,fill oul known well con.rnruchon iglbrnmlion and explain the nalure of the
repair under=2/remarks section or on the hack a/Ihi.c/orm. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details of well
8.Number of wells constructed: 1 construction details. You may also attach additional pages if necessary.
hor nndliple injection or non-traler.cuppli,wells ONLY irah dre same construction,you can
SUBMITTAL INSTUCTIONS
submil one form.
9.Total well depth below land surface: 37 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
or mahip/e ire//s list all deplhr iJdiJJerem(example-3@200'and 2t7n/00') construction to the following:
Unknown
10.Static water level below top of casing: (ft.) Division of Water Resources,Information Processing Unit,
1/water Jere/is above casing,use"," 1617 Mail Service Center,jRaleigh,NC 27699-1617
11.Borehole diameter: 4 (in.) 24b. For Infection Wells ONLY: In'addition to sending the form to the address in
HSA w/ Geoprobe 24aabove, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
13a.Yield(gpm) Method of test: 24c.For Water Supply&Injection Wells:
Also submit one copy of this form within 30 days ofcomplelionof
13b.Disinfection type: Amount: well construction to the county health(department of the county where
constructed.
Form GW-I North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013